Join our Network

What Type of Provider Are You *

Solo: Practitioner billing with your own Tax ID#. (If you are a provider joining an existing contract please click on Group Practice, and select 'I have a contract..') Group Practice (If you are a provider joining an existing contract, please click on Group Practice and select 'I have a contract.') Facility/Agency (including Waiver services or MyCare Ohio Home and Community-Based services.) Independent Provider: Individual provider of MyCare Ohio Home and Community Based Services for waiver eligible members. Pharmacist (If you are a Registered Pharmacist administering services independently as an Ohio Medicaid Provider)

Please select an option below *

I do not have a contract and need to apply I have a contract and need to add a Network or Additional Services

Please select the Networks or Services you wish to contract for *

Behavioral Health Medicaid Waiver Medicare Ambetter

Group Practice or Facility/Agency Name *

Legal Entity Name * As listed on the Form W-9

DBA Name

Tax ID Contracting For * Numbers only

Provider First Name *

Provider Last Name *

Individual NPI * Numbers only. Enter all 9's if you don't have an NPI

Practitioner Taxonomy

Practitioner OH Medicaid * Numbers only

Practitioner Medicare

Correspondence Address *

City *

State *

ZIP Code *

Primary Practice Street Address *

Primary Practice City *

Primary Practice State *

Primary Practice ZIP Code *

Primary Practice County *

Primary Practice Phone Number *

Secondary Practice Street Address

Secondary Practice City

Secondary Practice State

Secondary Practice ZIP Code

Contact Name *

Contact Phone *

Contact Fax

Contact Email *

Provider Email *

Before submitting this form, please download the documents listed below by right-clicking and choosing "Save link as" or "Save target as." Once the documents are complete, upload to the corresponding upload option at the end of this page.

Contract Services Form *

Disclosure of Ownership Form *

W-9 *

Please select the Networks or Services you wish to contract for *

Behavioral Health Medicaid Waiver Medicare Ambetter

Independent Provider Name *

Legal Entity Name * As listed on the Form W-9

DBA Name

Tax ID Contracting For * Numbers only

Provider First Name *

Provider Last Name *

Individual NPI * Numbers only. Enter all 9's if you don't have an NPI

Practitioner Taxonomy

Practitioner OH Medicaid * Numbers only

Practitioner Medicare

Correspondence Address *

City *

State *

ZIP Code *

Primary Practice Street Address *

Primary Practice City *

Primary Practice State *

Primary Practice ZIP Code *

Primary Practice County *

Primary Practice Phone Number *

Contact Name *

Contact Phone *

Contact Fax

Contact Email *

Provider Email *

Contract Services Form (PDF)
Disclosure of Ownership Form (PDF)
W-9 (PDF)
Home and Community-Based Provider Information Form (PDF)
Home Health Services Verification (a copy of the most recent correspondence from the Ohio Department of Medicaid that lists the home health services the provider/agency is certified provide to our members)

Contract Services Form *

Disclosure of Ownership Form *

W-9 *

Home and Community-Based Provider Information Form *

Home Health Services Verification *

Please select the Networks or Services you wish to contract for *

Behavioral Health Medicaid Waiver Ambetter Medicare

Group Practice or Facility/Agency Name *

Legal Entity Name * As listed on the Form W-9

DBA Name

Tax ID Contracting For * Numbers only

Group Or Facility Primary NPI * Numbers only. Enter all 9's if you don’t have an NPI

Organization OH Medicaid * Numbers only

Organization Medicare

Organization Taxonomy *

Correspondence Address *

City *

State *

ZIP Code *

Primary Practice Street Address *

Primary Practice City *

Primary Practice State *

Primary Practice ZIP Code *

Primary Practice County *

Primary Practice Phone Number *

Secondary Practice Street Address

Secondary Practice City

Secondary Practice State

Secondary Practice ZIP Code

Contact Name *

Contact Phone *

Contact Fax

Contact Email *

Provider Email *

Number of Practitioners Joining *

Contract Services Form *

Disclosure of Ownership Form *

W-9 *

Please select the Networks or Services you wish to contract for *

Behavioral Health Medicaid Waiver Ambetter Medicare

Group Practice or Facility/Agency Name *

Legal Entity Name * As listed on the Form W-9

DBA Name

Tax ID Contracted For * Numbers only

Group Or Facility Primary NPI * Numbers only. Enter all 9's if you don’t have an NPI

Organization OH Medicaid * Numbers only

Organization Medicare

Organization Taxonomy *

Correspondence Address *

City *

State *

ZIP Code *

Primary Practice County *

Primary Practice Phone Number *

Contact Name *

Contact Phone *

Contact Fax

Contact Email *

Provider Email *

Number of Practitioners Joining *

New Practitioner Enrollment Form (PDF)
Disclosure of Ownership Form (PDF)
Standard Direct Practitioner Roster (XLS) - Complete this roster if you are submitting enrollment for several practitioners not related to a CMHC or SUD.
W-9 (PDF)

If you are only submitting the direct roster for several practitioners please us the upload option for the New Practitioner Enrollment form to attach the roster.

New Practitioner Enrollment Form *

Disclosure of Ownership Form *

Standard Direct Practitioner Roster

W-9 *

Please select the Networks or Services you wish to contract for *

Behavioral Health Medicaid Waiver Medicare Ambetter

Group Practice or Facility/Agency Name *

Legal Entity Name * As listed on the Form W-9

DBA Name

Tax ID Contracting For * Numbers only

Group Or Facility Primary NPI * Numbers only. Enter all 9's if you don’t have an NPI

Does your Organization have multiple Facility/Agency NPIs on this application? *

Yes No

Additional NPIs Please enter your additional Facility/Agency NPIs that you are applying for separated by a single comma. Please do not input Individual practitioner NPIs in this field.

Organization OH Medicaid * Numbers only

Organization Medicare

Organization Taxonomy

Correspondence Address *

City *

State *

ZIP Code *

Primary Practice Street Address *

Primary Practice City *

Primary Practice State *

Primary Practice ZIP Code *

Primary Practice County *

Primary Practice Phone Number *

Secondary Practice Street Address

Secondary Practice City

Secondary Practice State

Secondary Practice ZIP Code

Contact Name *

Contact Phone *

Contact Fax *

Contact Email *

Provider Email *

Number of Practitioners Joining *

Number of Facilities Joining *

Contract Services Form *

Disclosure of Ownership Form *

W-9 *

Please select the services you wish to contract for* *

Behavioral Health Medicaid Waiver Medicare Ambetter

Group Practice or Facility/Agency Name *

Legal Entity Name * As listed on the Form W-9

DBA Name

Tax ID Contracted For * Numbers only

Group Or Facility Primary NPI * Numbers only. Enter all 9's if you don’t have an NPI

Does your Organization have multiple Facility/Agency NPIs on this application? *

Yes No

Additional NPIs Please enter your additional Facility/Agency NPIs that you are applying for separated by a single comma. Please do not input Individual practitioner NPIs in this field.

Organization OH Medicaid * Numbers only

Organization Medicare

Organization Taxonomy

Correspondence Address *

City *

State *

ZIP Code *

Primary Practice County *

Primary Practice Phone Number *

Contact Name *

Contact Phone *

Contact Fax

Contact Email *

Provider Email *

Number of Practitioners Joining *

Number of Facilities Joining *

New Facility Application (PDF) - Complete form for Facilities with Medical services only.
Behavioral Health Facility Application (PDF) - Complete form for Behavioral Health and for Behavioral Health Facilities with Medical services.
Disclosure of Ownership Form (PDF)
Behavioral Health CMHC or SUD Practitioner Roster (XLS) - Complete for Behavioral Health CMHC or SUD facilities if the facility has practitioners.
Standard Direct Practitioner Roster (XLS) - Complete this roster if you are submitting enrollment for several practitioners not related to a CMHC or SUD.
W-9 (PDF)

Facility Application *

Behavioral Health Facility Application

Disclosure of Ownership Form *

Behavioral Health CMHC or SUD Practitioner Roster

Standard Direct Practitioner Roster

W-9 *

Ohio Pharmacist Provider Status Frequently Asked Questions (PDF)

Please select the Networks or Services you wish to contract for *

Medicaid

Practice or Facility/Agency Name *

Legal Entity Name * As listed on the Form W-9

DBA Name

Tax ID Contracting For * Numbers only

Facility Primary NPI * Numbers only. Enter all 9's if you don’t have an NPI

Organization OH Medicaid * Numbers only

Organization Taxonomy *

Correspondence Address *

City *

State *

ZIP Code *

Primary Practice Street Address *

Primary Practice City *

Primary Practice State *

Primary Practice ZIP Code *

Primary Practice County *

Primary Practice Phone Number *

Secondary Practice Street Address

Secondary Practice City

Secondary Practice State

Secondary Practice ZIP Code

Contact Name *

Contact Phone *

Contact Fax

Contact Email *

Provider Email *

Number of Practitioners Joining *

Upload Contract Services Form*

Upload Disclosure of Ownership Form*

Upload W-9*